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Three Part Question

In [adults with suspected scaphoid fracture] which [is the best clinical test] to [diagnose this injury]

Clinical Scenario

A 41 year old female presents to the department hours after a FOOSH. She has pain on the radial side of the wrist and over the ASB. You wonder if she has had a fracture of the scaphoid and want to know the best clinical test to help the diagnosis

Search Strategy

MEDLINE 1966-2/11, CINAHL 1982 2/11, AMED 1985-2/11, SPORTDiscus 1830-2/11, EMBASE 1996-2/11, via the OVID interface. The Cochrane database, December 2009 and PEDro database, December 2009.

Medline, CINAHL, AMED, EMBASE, SPORTSDiscus, Cochrane database: [{(exp scaphoid bone OR exp carpal navicular bone OR scaphoid.mp) AND (fracture.mp) AND (examin$mp OR clinical test.mp)]
LIMIT to human AND English language AND diagnostic sensitivity and specificity.

Search Outcome

198 papers were retrieved, of which 6 were relevant to the 3 part question. 1 used MR imaging as the reference test and the other 4 used plain radiography, and 1 used a combination of plain radiography and scintigraphy.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Waeckerle et al, 1987, USA	N = 85 Reference standard: Plain radiograph	Diagnostic study 1a	1. Anatomical snuff box (ASB) tenderness	Sensitivity = 100% Specificity = 98% PPV = 0.97 NPV = 1
			2. Resisted supination	Sensitivity = 100% Specificity = 98% PPV = 0.97 NPV = 1
			3. Thumb axial compression (AC)	Sensitivity = 97.5% Specificity = 97.8% PPV = 0.95 NPV = 0.97
Powell et al, 1988, Canada	N = 73 Reference standard: Plain radiograph	Diagnostic study 1a	1. New test: pain in ASB during Pronation + Ulnar deviation	Sensitivity = 100% Specificity = 66% PPV = 52 NPV = 100	Age range not stated.
Chen, 1989, UK	N = 52 Reference standard: Plain radiograph	Retrospective study	1. Thumb AC	Sensitivity = 70.5% Specificity = 91% PPV = 0.85 NPV = 0.70	Retrospective study of 10-year period. Age range 11-85 yrs. No break down of results by age group.
Waizenegger, 1994, UK	N = 52 Reference standard = Plain or scinitgraphy	Diagnostic study 1a	1. Kirk-Watson test	Sensitivity = 82% Specificity = 31%	Poor description of clinical tests. Mixture of the reference gold standard test.
			2. Clamp test	Sensitivity = 26% Specificity = 79%
			3. ASB tenderness	Sensitivity = 87% Specificity = 38%
			4. Thumb AC	Sensitivity = 50% Specificity = 51%
			5. Pronation and UDev	Sensitivity = 83% Specificity = 17%
			6. Pronation and RDev	Sensitivity = 70% Specificity = 31%
			7. Resisted supination	Sensitivity = 83% Specificity = 38%
Parvizi et al, 1998, UK	N = 215 Reference standard: Plain radiograph	Diagnostic study level 1a	1. ASB tenderness	Sensitivity = 100% Specificity = 19% PPV = 0.3 NPV = 1	38 patients lost to follow up. Age range 6-79 years. No results breakdown by age.
			2. Thumb AC	Sensitivity = 100% Specificity = 48% PPV = 0.4 NVP = 1
			3. Scaphoid tubercle (ST) tenderness	Sensitivity = 100% Specificity = 30% PPV = 0.34 4. NPV = 1
			4. Loss of thumb ROM	Sensitivity - 66% Specificity = 66% PPV = 0.41 NPV = 0.85
			5. ASB + AC	Sensitivity = 100% Specificity = 54% PPV = 0.43 NVP = 1
			6. ASB + AC + ST	Sensitivity = 100% Specificity = 74% PPV = 0.58 NPV = 1
Unay et al, 2009, Turkey	N = 41 with occult fracture not visible plain film. Reference standard: MR scans	Diagnostic study 1a	1. Thumb ABD	Sensitivity = 73% Specificity = 50% PPV = 0.86 NPV = 0.31	Not stated who performed the clinical tests. Age range 9-50 years. Unclear if radiology images were scored independently.
			2. Wrist RDev	Sensitivity = 68% Specificity = 33% PPV = 0.93 NPV = 0.08
			3. Thumb AC	Sensitivity = 71% Specificity = 35% PPV = 0.54 NPV = 0.54
			4. Wrist Flexion	Sensitivity = 71% Specificity = 50% PPV = 0.89 NPV = 0.23
			5. Wrist Extension	Sensitivity = 72% Specificity = 60% PPV = 0.93 NPV = 0.23
			6. Power grip	Sensitivity = 67% Specificity = 20% PPV = 0.86 NPV = 0.08
			7. Wrist UDev	Sensitivity = 70% Specificity = 36% PPV = 0.75 NPV = 0.31
			8. Wrist Pro	Sensitivity = 79% Specificity = 58% PPV = 0.82 NPV = 0.54
			9. Wrist Sup	Sensitivity = 76% Specificity = 50% PPV = 0.79 NPV = 0.46
			10. Pinch grip	Sensitivity = 73% Specificity = 75% PPV = 0.98 NPV = 0.23

Comment(s)

Studies vary widely in diagnostic values for a variety of tests. Only one study used MR imaging as the gold standard. There is no consensus as to the best clinical test for a scaphoid fracture. ASB tenderness in all studies gave 100% sensitivity (i.e. if ASB tenderness is absent, then a fracture is highly unlikely). Specificity ranged from high, at 98% (i.e. if ASB tenderness is present then a fracture is likely) to low, at 19% (i.e. if ASB tenderness is present then a fracture is less likely). There is some evidence that a combination of tests (pain on ASB + AC + ST) will give perfect sensitivity and high specificity. Most clinical tests had higher sensitivity than specificity, which means that a fracture is unlikely to be missed but they will give a high number of false positives.

Clinical Bottom Line

A combination of clinical tests seems to give the best diagnostic values for a scaphoid fracture.

References

1. Waeckerle JF A prospective study identifying the sensitivity of radiographic findings and the efficacy of clinical findings in carpal navicular fractures. Annals of Emergency Medicine (1987); 16 (7): 733-737.
2. Powell JM ,Lloyd GJ, Rintoul RF. A new clinical test for fracture of the scaphoid. Canadian Journal of Surgery 1988; 31 (4):237-238.
3. Chen SC. The scaphoid compression test. Journal of Hand Surgery 1989; 14 (3): 323-325.
4. Waizenegger M, Barton NJ, Davis TR, et al. Clinical signs in scaphoid fractures. Journal of Hand Surgery 1994; 16 (6): 643-747.
5. Parvizi J, Wayman J, Kelly P, et al. Combining the clinical signs improves diagnosis of scaphoid fractures Journal of Hand Surgery 1998; 23 (3): 324-327.
6. Unay K, Gokcon B, Ozkan K et al. Examination tests predictive of bone injury in patients with clinically suspected occult scaphoid fracture. Injury 2009; 40: 1265-1268.